Warren Alpert Medical School of Brown University Warwick, RI, United States
Tamara Koritarov, DO, MSc Warren Alpert Medical School of Brown University, Warwick, RI
Introduction: Ingestion of only an ounce of a strong alkali can cause extensive damage to the gastrointestinal tract through transmural liquefactive necrosis, which carries a high morbidity and mortality. Tissue directly acts as a buffer attempting to limit the rapidly advancing necrosis resulting in complications such as esophageal perforation, mediastinitis, and death. Early endoscopy is critical to assess and grade the injuries to mucosa and provide prompt life-saving treatment.
Case Description/Methods: A 55-year-old male with a history of Crohn’s disease, hypertension, and GERD, presented with nausea and vomiting following accidental ingestion of one ounce of alkaline Potassium hydroxide (KOH) fertilizer solution. Vitals initially were stable, but within 30 minutes of arrival he became increasingly somnolent, tachypneic, and unable to manage secretions. He was emergently intubated for airway protection. CT images revealed secretions in the distal esophagus, thickening of the stomach wall, and bilateral pleural effusions concerning for aspiration. Emergent EGD found an entirely necrosed esophagus and stomach, with Zargar caustic ingestion injury Grade 3B. Thoracic surgery evaluation revealed a bronchoesophageal fistula that required urgent closure of the left main bronchus fistula, lateral flap reinforcement, esophagogastrectomy, open j-tube placement, and tracheostomy. His recovery was complicated by copious pulmonary secretions requiring bronchoscopy, respiratory failure requiring VV ECMO, acute renal failure requiring hemodialysis, development of atrial fibrillation then cardioverted, persistent bacteremia and mediastinitis, MRSA pneumonia, partial small bowel obstruction requiring exploratory laparotomy and small bowel resection, stricture of esophagectomy requiring dilation of cervical esophagostomy with fusion of epiglottis to posterior oropharynx and placement of salivary bypass tube. After a prolonged hospital stay, he was discharged to a rehab facility.
Discussion: Ingestion of a caustic alkaline agent causes severe injury to the mucosa within seconds. Respiratory distress is a sign of perforation or direct mediastinal extension of esophageal necrosis with devastating complications. Emergent esophagectomy and fistula repair with a muscle flap is lifesaving however it is infrequently performed due to the rarity of such cases. This case of bronchoesophageal fistula highlights successful early evaluation and repair and can support the development of evidence-based guidelines for directed therapy.
Figure: Figure 1: CT Abdomen revealed thickening and air in mucosa of the gastric wall Figure 2: EGD images of middle third of esophagus (left) and gastric body (right) with extensive necrosis of mucosa, the entire circumferential length of esophagus was completely necrosed and edematous Figure 3: CT Chest shows secretions in the distal esophagus and bilateral consolidations in lower lobes concerning for aspiration
Disclosures: Tamara Koritarov indicated no relevant financial relationships.
Tamara Koritarov, DO, MSc. P2445 - Bronchoesophageal Fistula After Accidental Fertilizer Ingestion Resulting in Esophagectomy, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.